Forms

Skip to Main Content

Common Forms

For more information about OneCare (HMO SNP) or to enroll, please call us at 1-800-960-9070 (toll free) 24 hours a day/7 days a week. Or visit our office Monday through Friday from 8 a.m. to 5:30 p.m. Pacific Time (walk-ins welcome). Members with hearing or speech impairments can call our TDD/TTY line at 1-800-735-2929. We also provide interpreter services at no cost to our members. We have staff who speak your language.

Find Common Forms

We want to make it easy for you to find the forms you need. If you don't see the form you are looking for, or if you aren't sure which one you need, please call our Customer Service Department at the number on the right side of the screen. We are here to help you.

A

Appeals and Grievance Form

Appeals and Grievance Form - Spanish

Appeals and Grievance Form - Vietnamese

Appointment of Representative Form

Authorization for Use or Disclosure of Protected Health Information (PHI)

Authorization for Use or Disclosure of Protected Health Information (PHI) - Spanish

Authorization for Use or Disclosure of Protected Health Information (PHI) - Vietnamese

E

Enrollment Form

Enrollment Form - Spanish

Enrollment Form - Vietnamese

I

Individual Request for Protected Health Information (PHI) Access

Individual Request for Protected Health Information (PHI) Access - Spanish

Individual Request for Protected Health Information (PHI) Access - Vietnamese

S

Suspected Fraud or Abuse Referral Form

H5433_08244 Pending CMS Approval. OneCare (HMO SNP) is a Medicare approved HMO.

Materials available on this Website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe Website,
click here.

Language

Text Size

A
A
A